Provider Demographics
NPI:1790517134
Name:DOUGLAS, BRONWYN LEOLA
Entity type:Individual
Prefix:
First Name:BRONWYN
Middle Name:LEOLA
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1881 PILLSBURY DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-9623
Mailing Address - Country:US
Mailing Address - Phone:785-317-0522
Mailing Address - Fax:
Practice Address - Street 1:206 SOUTHWIND PL STE 2C
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-3131
Practice Address - Country:US
Practice Address - Phone:785-477-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03614-T106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist